Private psychology practice is no longer a cottage industry. It requires vision, clinical expertise, leadership and business acumen. I would like to share with those of you who are like myself who will venture into private psychology practice whether it be as a solo provider working in a GP clinic or in a group practice situation some of the Business Tips I have gleaned from working in private psychology practice for nearly 30 years.
1. What goes around comes around
Most people know this saying. But do you know what it means in regards operating a private psychology practice? It means that if you give a bit you will get a return in spades. What do I mean? If you are tough on your staff or your contractors/colleagues who are working with you, don’t expect that they will go the extra mile to build what they may perceive as your business. Put another way if you can find ways to appreciate your staff and colleagues then you are more likely to promote loyalty to your practice and a strong work ethic in regards their clients.
2. Listen to your colleagues/staff and ask them what they want out of being in your practice
You need to be able to communicate your vision of the practice but also ask those who are working for the practice what motivates them, what they want from working with you. For some it might be supervision, or flexibility of hours or the opportunity to see a certain type of client, or peer consultation meetings, or car parking (!). You might be surprised what annoys your staff or colleagues and what a difference you addressing their issue can make to the atmosphere in the practice and overall compliance with your policies and procedures.
3. You are a leader so act like one
Women in leadership. Without making sweeping statements, it is one thing to be a good clinician and have good client retention, few no shows and positive client outcomes, it is another to mentor those around you to achieve the same. If you don’t have the clinical experience to offer supervision and consultation, then think about how you can ‘buy in’ or create opportunities for professional development and consultation in the practice. Put time aside to build your leadership, networking with others to find out what are the best ways to operate a practice. Look to other allied health professionals and their practices in your local area and see if they are interested in discussing ways of working together and sharing business knowledge. You may be surprised what quality time put aside for building your knowledge and capacity as a leader might deliver to your practice.
4. Mediocrity will not win the day
Operating a small-medium size business is not easy particularly if you are “early career” in your professional journey, have other family commitments and have limited business experience or training. Close enough will not be good enough to compete with other psychologists around you who are offering similar services. The answer is not necessarily a big PR campaign on social media. Look at what you are doing in the practice—are your fellow clinicians using best evidence practice? Do you routinely seek feedback from clients as to treatment effectiveness? Do you have access to appropriate psychometric tests and other resources that your clinicians can utilise with clients? Do you regularly audit your practice files to check on Medicare compliance, good note taking practice (e.g. evidence of assessment of clients, treatment planning and goal setting and review of progress) and adherence to policies and procedures. Do you put aside time to monitor the practice—on the clinical side and the business side?
5. Clinical Governance
Governance is not to do with Government per se. Most of the definitions of clinical governance and what it entails are written for public health institutions such as hospitals. Increasingly however, interest is being directed at psychologists. Our profession is the recipient of government funding through Medicare payments and questions of the accountability for that trust put in us, concerns about our risk management and whether we are focused on clinical effectiveness through continuous improvement processes are being asked. Complaints about psychologists to authorities are often about poor business practices, lack of communication with the patient/client about fees or limits of confidentiality or about the length and type of treatment, poor report writing, and the like. Do you have systems in place to monitor quality assurance? What is your risk management strategy? How do you address leadership and culture in your practice in such a way that it privileges the client’s experience? What do you do when a client complains about a service or a practitioner? Are they sounding an alert about deeper problems you may need to address? 20 % of psychologists are likely to have a complaint against them over their career.
6. What do you know about your practice? Make decisions on evidence and facts not hunches and anecdotes
Do you know how many hours you or the practitioners working in your practice see clients vs how many available hours there in any one day? What conversion rate of percentage of clients to available hours would you say was reasonable? Does it pay your overheads? What about referrals—which GPs refer how many of your clients and have these numbers gone up or down over the last 12, 6 or 1 month and do you know why? When clients don’t show up for appointments what are your expectations of the role of administration staff in follow up vs the role of practitioners in calling clients to check on their well being and to see if they would like to re-commence their treatment plan. A cancellation fee is unlikely to motivate a client who is possibly a drop out to re-engage. When I ask my practitioners if they are ‘punishing’ their clients for not showing when they want cancellation fee invoices sent out they are often aghast but it does start the conversation about who has the problem in regards a drop out from treatment and why did the drop out occur.
7. Policies and Procedures will get you where you want to be
Do you have information that goes out to clients when they book first appointments? Do you have a client agreement to treatment form and a consent form for transfer of information? Do you have a communication policy which covers how your clinic communicates with the psychologists, the clients, the referrers etc? What about an appointment and cancellation policy, waitlist policy, Medicare compliance policy and procedures? Risk assessment policy for administration staff and also one for the psychologists? What is your policy on treating multiple family members at your clinic and how does confidentiality apply here? What is your policy on client’s who drop out of treatment and what do you think is your responsibility for follow up with such clients and their referrers?
Essentially all administration process whether they are policies or procedures are only as good as the monitoring of compliance and non-compliance. Such monitoring is part of good governance, is ethically required in my view and reinforces the high standard of care and consideration that you wish to convey to your clients and referrers. Monitoring compliance is essential as it allows you to answer questions such as: When should the cancellation fee be waived? Or If a client does not show up for an appointment and/or does not re-schedule are they still your responsibility? Or What information should be collected by administrative staff and what should be collected by the psychologist and what should be supplied in writing prior to the first appointment. Some clinics try to shift the administrative load onto the client by asking for them to fill out a 10-15 page assessment document which amounts to the equivalent of ‘War and Peace’ about aspects of the client’s history or lifestyle that may or may not be relevant to their presenting problem. Is this part of the Assessment process and if so how does that material integrated with the clinical or assessment interview? As fast as you set a policy and procedures, something will come up in the practice that challenges it or leads to questions as to whether the policy is correct or whether the procedure does not follow the policy and why doesn’t it? Reporting processes helps with the recursive review of policies and procedures which is a key role for the Managing Clinician whether you are managing yourself, a small team or a multiple site large practice.
8. Which standards should we be measuring ourselves by?
Standards are often associated with accreditation processes. Psychology private practices have not been accredited traditionally in Australia unlike our GP colleagues who are incentivised to undergo accreditation. Interestingly, GP practice accreditation is voluntary not mandated. In terms of professional standards, the APS devised some years ago the Professional Practice Management Standards manual which was a self-assessment process for psychologists to undertake against 5 Professional Practice areas: Provision of Services, Rights, responsibilities and safety, Management of client information, Quality assurance and continuing education and Business and personnel management. In my view, times have moved on and there is a need to address standards in psychology private practice so that they are aligned with the National Mental Health Standards, the Australian Safety and Quality framework for Health Care. These and other strategies and policies devised by Government are primarily targeting safety of the public and high quality care.
A possible framework for reviewing a practice against standards could look like this:
Rights & responsibilities
Provision of Services
Outcome focused/collaborative care
Integrated service delivery
Continuous improvement and QA
Best evidence practice
Co-ordination of care
Governance: HR, information systems, adherence to standards systems
Third party responsibilities
Methods of measuring yourself against the standards need to be devised. A personalised improvement plan that could be reviewed regularly would then follow on from the initial assessment.
9. Know your outcome research
Leading psychology authors and thinkers such as Mary Sykes Wylie, Scott Miller, Mary Pipher, Scott Lilienfeld, Chloe Madanes, William Doherty all contributed to an edition of Psychotherapy Networker (March/April 2015). In summary, they noted that the real threats to the future of psychology practice were:
- A lack of a coherent description of what we do that the public can understand;
- That we stubbornly cling to intuition and personal experience as guiding lights in our work rather than trusting science and research to guide us;
- That we don’t market as well as we might the strength of the solutions we offer to human problems: empathy, goal collaboration and consensus, a professional relationship and therapeutic method of communication with clients that incorporates client feedback which has been shown to deliver superior results.
So you need to develop a style of practice that works and is effective for you with your potential clients. Most psychologists trained in Australia should have a reasonable level of applied competence with cognitive and behaviourally based therapies. A positive outcome for clients is usually enhanced by collaboration with the client in setting goals that are focused on their reason for presenting for treatment and provision of interventions that reflect the capabilities of the practitioner. In other words, becoming good at one of two psychological treatment approaches is better than having undertaken minimal training in a number of approaches. Whilst clients will have a preference for the means and methods by which you deliver psychological treatment to them, they are more likely to improve if they acquire a more adaptive explanation for their problems through psychological treatment (Wampold & Imel, 2015; O’Donovan et al, 2013).
In writing about how to adapt psychology treatment to address individual client needs, Norcross & Lambert (2013) suggested that six trans-diagnostic features should be considered for each client: reactance level (compliance-defiance continuum), stages of change, preference for treatment modality (e.g., psychotherapy vs medication), therapy method (e.g., CBT, ACT, etc.), therapist characteristics (e.g., gender) and treatment length.
The following is a brief summary of their suggestions for effective psychology treatment:
- Systematically vary your directness with client to enhance treatment results and to decrease drop outs.
- Methods: Psycho-education and emotion generating counselling methods work best for clients contemplating change while skills training and behavioural methods work best for those who are in the action stage.
- Client preferences: an intake or first session review that recognizes and accommodates to the preferences of clients. This will include treatment method, therapist characteristics and treatment length. Doing this is likely to reduce barriers to treatment.
- Coping style: The client’s pre-dominant coping style (blame themselves ‘internalisers’, act out ‘externalisers’ for example) should be matched to the focus of treatment so as to enhance treatment outcome: internalising clients tend to find interpersonal and insight-orientated treatments more effective while symptom-focused and skill building treatment tend to be more effective among externalising clients.
Overall, the outcome research suggests that reducing symptoms and stabilising clients initially and then switching to more indirect or insight oriented approaches is likely to be effective with most clients. Using outcome measures that measure progress over time on a measure such as general well-being that can be given every session (Outcome Rating Scale) and the therapeutic alliance (Session Rating Scale) are more likely to reduce drop outs, improve adherence to a treatment plan and create a strong client centred practice.
Bruce Wampold in a meta-analysis of what works in treating PTSD (2010, Clinical Psychology Review 30, 923–933) noted that there trauma focused and non-trauma focused psychological treatment methods are equally effective and that the factors important to the successful treatment of PTSD are:
Cogent psychological rationale that is acceptable to patient
Systematic set of treatment actions consistent with the rationale
Development and monitoring of a safe, respectful, and trusting
Collaborative agreement about tasks and goals of therapy
Nurturing hope and creating a sense of self efficacy
Psychoeducation about PTSD
Opportunity to talk about trauma (i.e., tell stories)
Ensuring the patient’s safety, especially if the patient has been victimized as
in the case of domestic violence, neighborhood violence, or abuse
Helping patients learn how to avoid revictimization
Identifying patient resources, strengths, survival skills and intra and
interpersonal resources and building resilience
Teaching coping skills
Examination of behavioral chain of events
Exposure (covert in session and in-vivo outside of session)
Making sense of traumatic event and patient’s reaction to event
Patient attribution of change to his or her own efforts
Encouragement to generate and use social supports
If you take our specific references to ‘PTSD’ many of these factors apply to all successful psychotherapy or psychological treatment in my view.
10. Personal challenges to change over time as a psychologist in private practice
There is no doubt that in your life time and career, you will see many aspects of private psychology practice change and develop. Many of the challenges will come from government in all its forms but the most important part of private practice is self-management and knowing when you need to change. Below is a model devised by psychologist coaches: Dr Anthony Grant and Dr David Cavanagh from University of Sydney that I find helpful when making changes in my practice.
Stay the Same
Brainstorm the upsides of staying the same- write these down in this box. Identify the person’s underlying psychological needs- the hidden payoffs. Explore ambivalence. Look for their underlying needs.
Make a Change
Brainstorm the upside of making a change. These will be very similar to step 1, but here you should expand on these issues in detail, so that the benefits of change are clear, obvious and plentiful. Then make sure that the person’s needs are met by the change. Generate self-motivational statements. Drill down to the personal- “want tos”- not “shoulds”.
Brainstorm the downside of staying the same- write these down in this box. Keep this quite short.
Develop an action plan to enact the change. Write it down. If high levels of doubt or uncertainty remain, explore the barriers to change.
Enlisting the help of a supervisor, coach/business mentor, a good accountant and a legal advisor are all integral to revising and reflecting on your goals and vision for your practice. Setting aside time to deliberately practice your skills and reflect on your performance in your practice is vital and can only happen if you expose your work and your practice to constructive scrutiny. What you achieve in your practice will be determined by what goes on outside of therapy room as much as what goes on within it.
11. Give back to the community
We are privileged as health professionals. Clients confide in us and we in turn learn about ourselves and life through our work. All of these experiences give us important skills and capabilities that we can in turn give to the community whether it is through free talks to various community groups on psychology topics or volunteering to join a committee or get involved in a project. Joining your peers in professional networking on a regular basis allows you to keep in touch with the world outside your practice room. It is an opportunity to take advice from others and share common issues that can arise in the isolated world of private practice. Put aside time for this as part of the process of remaining connected with the profession. It will also pay back to you in ways you can’t know at the outset.